Hindfoot alignment assessment by the foot-ankle offset: a diagnostic study.

INTRODUCTION: Foot-ankle offset (FAO) is a three-dimensional (3D) biometric measurement of hindfoot alignment (HA) measured on images from weight-bearing computed tomography (WBCT). Our aim was to investigate its distribution in a large cohort of patients, hypothesizing that threshold FAO values in valgus or varus could be identified as markers for increased risk of associated pathologies. MATERIALS AND METHODS: Prospective, monocentric, level II study including 125 subjects (250 feet) undergoing bilateral WBCT [58.4% female; mean age, 54 years (18-84)]. Patients were clinically assessed and pathologies were classified according to anatomic location (valgus- or varus associated). HA was measured using FAO on 3D datasets and tibio-calcaneal angles (TCA) on two-dimensional Saltzman-El-Khoury views. Threshold FAO values and area under the receiver operating characteristics curve (AUC) were calculated for predicting increased risk of medial or lateral pathologies. RESULTS: Mean FAO was 1.65% ± 4.72 and mean TCA was 4.15° ± 7.67. Clinically, 167 feet were normal, 33 varus and 50 valgus with FAO values of 1.71% ± 3.16, - 4.96% ± 5.30 and 5.79% ± 3.77, respectively. Mean FAO was 0.99% ± 3.26 for non-pathological feet, - 2.53% ± 5.05 for lateral and 6.81% ± 2.70 for medial pathologies. Threshold FAO values of - 1.64% (51.4% sensitivity, 85.1% specificity, AUC = 0.72) and 2.71% (95% sensitivity, 82.8% specificity, AUC = 0.93) best predicted the risk of lateral and medial pathology, respectively. CONCLUSION: Patients with FAO between - 1.64% and 2.71% had the least risk of degenerative foot and ankle pathology. This interval could be considered a target for patients undergoing realignment procedures. CLINICAL RELEVANCE: A "safe zone" for Foot Ankle Offset was described between - 1.64% and 2.71%, for which the risk of foot and ankle pathologies is lower. LEVEL OF EVIDENCE: II-Diagnostic study.

Tendoscopy of Achilles, peroneal and tibialis posterior tendons: An evidence-based update.

BACKGROUND: Tendoscopy has been proposed in treating several conditions affecting tendons around the ankle. We reviewed literature to investigate the efficacy of Achilles, peroneal and tibialis posterior tendoscopy. METHODS: Following the PRISMA checklist, the Medline, Scopus and EMBASE databases were searched, including studies reporting patients affected by disorders of Achilles, peroneal and tibialis posterior tendons and treated by tendoscopy (or tendoscopic-assisted procedures). The tendoscopic technique, rehabilitation protocol, clinical scores, patient satisfaction, success and failure rates and complications were evaluated. RESULTS: Sixteen studies (319 procedures) dealt with Achilles tendoscopy, nine (108) and six (78) about peroneal and tibialis posterior, respectively. Wound healing, cosmetic results, complication rate, work and sport resumption delay were satisfactory. Clinical scores, classification methods and rehabilitation protocols adopted were heterogeneous. CONCLUSIONS: The recent scientific evidence suggests that tendoscopy and endoscopic-assisted percutaneous procedures are a safe and effective treatment in chronic and acute disorders of tendons around the ankle.

Revision tibiotalar arthrodesis with posterior iliac autograft after failed arthroplasty: A matched comparative study with primary ankle arthrodeses.

INTRODUCTION: Tibiotalar arthrodeses performed after failed ankle arthroplasties are known to be complex procedures with often disappointing functional outcomes. This study reports the results of a revision technique using a posterior iliac crest autograft. HYPOTHESES: We hypothesized that: (1) revision tibiotalar arthrodeses (RTTAs) had functional outcomes which were similar to those of a reference cohort of primary tibiotalar arthrodeses (TTAs) and that (2) the union rate was satisfactory. MATERIALS AND METHODS: This retrospective study compared 16 RTTAs performed for failed arthroplasties that caused pain and a functional disability (4 aseptic loosening, 4 massive progressive periprosthetic cysts, 5 malpositioning of implants, and 3 cases of unexplained mechanical pain) with a series of 16 primary TTAs performed for painful ankle osteoarthritis. The groups were matched at a 1:1 ratio for age, sex, side and body mass index. The preoperative workup included a physical exam, the American Orthopaedic Foot and Ankle Society (AOFAS) score, weight bearing radiographs, CT and SPECT scans. Outcomes were assessed both clinically (AOFAS score) and radiographically (X-rays and scans). The mean duration of the procedure (DP), average length of stay (LOS), fusion and complication rates, and time to union were also compared. RESULTS: At the mean follow-up of 30 months (range, 12-88) for the RTTA group and 59 months (range, 23-94) for the TTA group (p=.001), the AOFAS score increased from 27 to 70.8 points (p<.001) and from 29.8 to 76.2 points (p<.001), respectively; values were similar at the last follow-up (p=.442). Both groups had similar fusion (94%) and complication rates (12%). The DP was 196.9±33.6min (range, 179-213) vs. 130±28.4min (range, 118-141) (p<.001) and the LOS was 3.8 days (range, 2-6) vs. 3.9 days (range, 2-6) (p<.445) for both groups (RTTA vs. TTA). CONCLUSION: This RTTA technique using a posterior iliac crest allograft for filling bone defects was validated by the quality of the functional outcomes obtained. LEVEL OF EVIDENCE: IV; Comparative retrospective study.

Comparison of 25 ankle arthrodeses and 25 replacements at 67 months' follow-up.

INTRODUCTION: In the treatment of osteoarthritis of the ankle, controversy persists between advocates of arthrodesis and of joint replacement. HYPOTHESIS: Results of total ankle replacement (TAR) are equivalent to those of ankle arthrodesis (AA). MATERIAL AND METHODS: A single-center continuous retrospective series included 50 patients (25 TAR, 25 AA) operated on by a single surgeon. TAR used the standard Salto® mobile-bearing prosthesis, and arthrodesis used screws or plates. Results were assessed clinically on AOFAS score, visual analog scale (VAS) and satisfaction questionnaire, and radiologically on X-ray and CT. Survivorship in the 2 procedures was estimated on the Kaplan Meier method. RESULTS: At a mean 67 months' follow-up (range, 40-105 months), mean AOFAS and VAS scores were significantly better in the AA group (74.1 and 1.9, respectively) than in the TAR group (67 and 3.5, respectively) (p<0.001). In the AA group, 80% of patients were satisfied or very satisfied, compared to 64% after TAR. Five-year survival without revision for non-union (AA) or implant removal (TAR) was similar between groups: AA, 96%; TAR, 90% (p=0.72). In contrast, survival with no revision procedures was significantly better with AA (96%) than TAR (75%) (p=0.03). DISCUSSION: At 5 years, surgical revision rates were significantly greater than after standard Salto® mobile-bearing TAR than for arthrodesis, notably due to onset of cysts; we therefore decided to abandon this implant. LEVEL OF EVIDENCE: IV, comparative retrospective study.

Role of Tendoscopy in Treating Stage II Posterior Tibial Tendon Dysfunction.

BACKGROUND: Stage II tibialis posterior tendon dysfunction (PTTD) resistant to conservative therapies is usually treated with invasive surgery. Posterior tibial tendoscopy is a novel technique being used in the assessment and treatment of posterior tibial pathology. The aims of this study were (1) to clarify the role of posterior tibial tendon tendoscopy in treating stage II PTTD, (2) to arthroscopically classify spring ligament lesions, and (3) to compare the arthroscopic assessment of spring ligament lesions with magnetic resonance imaging (MRI) and ultrasonographic (US) data. METHODS: We reviewed prospectively collected data on 16 patients affected by stage II PTTD and treated by tendoscopy. We report the reoperation rate and functional outcomes evaluated by comparing pre- and postoperative visual analogic scale for pain (VAS-pain) and the Short-Form Health Survey (SF-36; with its physical [PCS] and mental [MCS] components). Postoperative satisfaction was assessed using a VAS-satisfaction scale. One patient was lost to follow-up. Spring ligament lesions were arthroscopically classified in 3 stages. Discrepancies between preoperative imaging and intraoperative findings were evaluated. RESULTS: At a mean of 25.6 months' follow-up, VAS-pain ( P < .001), SF-36 PCS ( P = .039), and SF-36 MCS ( P < .001) significantly improved. The mean VAS-satisfaction score was 75.3/100. Patients were relieved from symptoms in 80% of cases, while 3 patients required further surgery. MRI and US were in agreement with intraoperative data in 92% and 67%, respectively, for the tendon assessment and in 78% and 42%, respectively, for the spring ligament. CONCLUSIONS: Tendoscopy may be considered a valid therapeutic tool in the treatment of stage II PTTD resistant to conservative treatment. It provided objective and subjective encouraging results that could allow continued conservative therapy while avoiding more invasive surgery in most cases. MRI and US were proven more useful in detecting PT lesions than spring ligament tears. Further studies on PT could use this tendoscopic classification to standardize its description. LEVEL OF EVIDENCE: Level IV, therapeutic study, case series.

Joystick of the Talus for Correcting Malalignment During Arthroscopic Ankle Arthrodesis: A Surgical Tip.

Ankle arthrodesis has been widely reported as an effective solution in treating tibiotalar joint osteoarthritis. The arthroscopic tibiotalar approach for arthrodesis has also been proven to give excellent results in terms of bone fusion rates and reduction of wound-related pain and complications. Historically, ankle malalignment has represented one of the main contraindications for the arthroscopic procedure, but interestingly some investigators have shown that the coronal joint deformity may be addressed arthroscopically as well. Other investigators have also demonstrated that part of the valgus/varus is due to malrotation of the talus within the mortise; therefore, controlling the talar position becomes crucial for correcting more severe deformities. We present here a technique for correcting tibiotalar malalignment during arthroscopic arthrodesis in varus or valgus ankles, performed through a K-wire used as a joystick to manage the talar position on both the coronal and axial planes.

Minimally Invasive Surgery Osteotomy of the Hindfoot.

A minimally invasive surgical approach has been developed for hindfoot as well as forefoot procedures. Percutaneous techniques have been evolving for more than 20 years. Many conventional surgical techniques can be performed percutaneously after training. Percutaneous surgical techniques require knowledge specific to each procedure (eg, percutaneous Zadek osteotomy or percutaneous medial heel shift). In the treatment and correction of the hindfoot pathology the surgeon now has percutaneous options including medial or lateral heel shift, Zadek osteotomy, and exostectomy with/without arthroscopy.